Another Take on Not Smoking, the Law and Tolerance

The New Yorker published a story this week, on smoking, that caught my attention. It’s by none other than F. Scott Fitzgerald. The author died in 1940 at the age of 44, after a ruinous period of addictions including alcoholism, debts and other problems.

F. Scott Fitzgerald (June, 1937), photo by Carl van Vechten

Thank You for the Light dates to 1936. The main character is a woman: “Mrs. Hanson was a pretty, somewhat faded woman of forty…” She sold girdles and craved cigarettes. Smoking had the power to “rest and relax her psychologically.” He describes her growing frustration at not being able to take a drag in offices where she did business.

The story suggests that although public and workplace smoking wasn’t illegal back then, it was frowned upon in cities like Chicago. The protagonist longs for past years and places where she could chat and share a drink or cigarette with clients after work. Times had changed, she reflects.

In Fitzgerald’s words:

…Not only was she never asked if she would like to smoke but several times her own inquiry as to whether anyone would mind was answered half apologetically with ‘It’s not that I mind, but it has a bad influence on the employees.’

This vignette offers a 1930s perspective on what some call social health – that an individual’s behavior might be influenced by neighbors’ and coworkers’ attitudes. In this story, the woman finds solace in a church. I won’t give away the ending.

The short read lingers. What’s unsettling, still, is whether the socially-driven ban on smoking helped or harmed the woman.

According to the New Yorker’s Page-Turner, the magazine rejected Fitzgerald’s story when he submitted the piece. The writer’s granddaughter recently uncovered it. This time around, it passed muster.

 

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What Does a Bikini Parade Have to Do with Breast Cancer?

A recurring question on this blog is this: Is there a limit, in terms of appropriateness or “correctness,” in fundraising for causes that would help put an end to breast cancer?

My blogging colleague and friend, fellow BC ~survivor/advocate/NBCC summit attendee and former chemo recipient, AnneMarie Ciccarella, @chemobrainfog wrote about an upcoming bikini parade planned by a tanning salon owner in Madison Lake, MN. Proceeds from the march will go toward a nonprofit group called the Breast Cancer Natural Prevention Foundation (preventbc.org). This true story is problematic at many levels, as AnneMarie points out.

But sometimes an extreme case of something – here what’s billed as a BC fundraiser – can be instructive. A few months ago I wrote about Boobstagram – a French website that asks women to submit pictures of their breasts to increase awareness of the value of healthy breasts. The site, vaguely and with few words, tries connecting the barely clad images with “the fight against cancer.” Although I’m still not convinced that the concept utterly lacks merit in principle, and maintain that some of the voices raised here were, perhaps, too quickly dismissive and uptight about the possibility of fundraising or BC activism by this method, I acknowledge that the men running that company seem to be doing nothing useful in terms of reducing breast cancer or its complications.

The Minnesota bikini march will take place on July 28. The line-up starts at noon. The walk will begin at 1PM. According to the announcement on the Electric Beach Mankato website, “only females in bikinis will be counted toward the world record.” The organizer and salon owner, Cynthia Frederick, needs 451 participants to break the Guinness World Records mark for largest bikini parade. That site lists the record as 357 women, based on a 2011 event in Queensland, Australia. But that achievement was recently surpassed in Panama City, FL. What’s different about the prior demonstrations is that there was no pretense of raising money or awareness to help fight, prevent or cure breast cancer.

Minnesota bikini parade participants will pay $20 or $25 for tee shirts. Net proceeds will to go the Breast Cancer Natural Prevention Foundation. The foundation’s site suggests that sunlight prevents BC by increasing vitamin D levels (which is total BS, to be perfectly clear). Taking too much vitamin D can do damage, as can excessive sun exposure.

As I read this, a tanning salon – a business that causes melanoma and other skin cancers – is promoting a walk of bikini-wearing women in midday summer sun to break an amusing world’s record. The parade will, if anything, harm those women who, naively or otherwise, believe they’re supporting a legitimate effort to prevent breast cancer. Any funds raised will support a foundation that promotes what’s tantamount to snake oil for the disease.

So there is a line, in the sand… And it’s been crossed!

If I were an investigative journalist, I’d want to know more about the organization that calls itself the “Breast Cancer Natural Prevention Foundation.” Does it get tax breaks? If so, why?

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This Week’s Triple, Tough Dose of Real Stories on Women with Cancer

Dear Readers,

It’s been a tough week on the breast cancer front.

Many in the community first learned that Ellen Moskowitz, a former leader at the Metastatic Breast Cancer Network (MBCN), died. Ellen was a funny, articulate woman who lived with MBC. When I interviewed her for an article on the value of a day designated to awareness about metastatic disease, she kept me laughing.

Robin Roberts, a co-host of Good Morning America who was treated for breast cancer less than 5 years ago, announced that she’ll be getting a bone marrow transplant for MDS. The blood condition is, in some cases, a complication of chemotherapy. I wrote a piece about this for the Atlantic Health. This unfortunate news reminds us an aspect of cancer treatment some of us would rather put out of our heads. The main message – which I hope came through editing – is that all cancer patients should take careful notes on their planned treatments and ask their doctors about the long-term consequences of therapy. Not all chemo is the same; the risks vary among regimens and doses. The reality is that some of us – patients and doctors – prefer not to think about late, long-term, possible effects of treatment, like secondary tumors, when there’s a life-threatening condition in hand. This doesn’t mean chemo isn’t the right choice. Often it is, but it should be weighed out, carefully.

Finally, we learned that Dr. Susan Love, a breast surgeon and professor at UCLA, and leader of an Army of Women, has leukemia. Dr. Susan Love’s Breast Book is a reference my friends and patients turned to in the 1990s, before the Internet was so loaded with cancer info, and many still do. She has, through that book and through her Foundation, besides through her work as a surgeon, helped an army of women to heal, and more.

My thoughts are with each of these remarkable women, and their loved ones, now.

ES

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New Article on Mammography Spawns False Hope That Breast Cancer is Not a Dangerous Disease

This week’s stir comes from the Annals of Internal Medicine. In a new analysis, researchers applied complex models to cancer screening and BC case data in Norway. They estimated how many women found to have invasive breast cancer are “overdiagnosed.” I cannot fathom why the editors of the Annals gave platform to such a convoluted and misleading medical report as Overdiagnosis of Invasive Breast Cancer Due to Mammography Screening: Results From the Norwegian Screening Program. But they did.

Here are a few of my concerns:

1. None of the four authors is an oncologist.

2. The researchers use mathematical arguments so complex to prove a point that Einstein would certainly, 100%, without a doubt, take issue with their model and proof.

3. “Overdiagnosis” is not defined in any clinical sense (such as the finding of a tumor in a woman that’s benign and doesn’t need treatment). Here, from the paper’s abstract:

The percentage of overdiagnosis was calculated by accounting for the expected decrease in incidence following cessation of screening after age 69 years (approach 1) and by comparing incidence in the current screening group with incidence among women 2 and 5 years older in the historical screening groups, accounting for average lead time (approach 2).

No joke: this is how “overdiagnosis” – the primary outcome of the study, is explained. After reading the paper in its entirety three times, I cannot find any better definition of overdiagnosis within the full text. Based on these manipulations, the researchers “find” an estimated rate of overdiagnosis attributable to mammography between 18 -25% by one method (model/approach 1) or 15-20% (model/approach 2).

4. The study includes a significant cohort of women between the ages of 70-79. Indolent tumors are more common in older women who, also, are more likely to die of other causes by virtue of their age. The analysis does not include women younger than 50 in its constructs.

5. My biggest concern is how this paper was broadcast – which, firstly, was too much.

Bloomberg News takes away this simple message in a headline:  “Breast Cancer Screening May Overdiagnose by Up to 25%.” Or, from the Boston Globe’s Daily Dose, “Mammograms may overdiagnose up to 1 in 4 breast cancers, Harvard study finds.” (Did they all get the same memo?)

The Washington Post’s Checkup offers some details: “Through complicated calculations, the researchers determined that between 15 percent and 25 percent of those diagnoses fell into the category of overdiagnosis — the detection of tumors that would have done no harm had they gone undetected.” But then the Post blows it with this commentary, a few paragraphs down:

The problem is that nobody yet knows how to predict which cancers can be left untreated and which will prove fatal if untreated. So for now the only viable approach is to regard all breast cancers as potentially fatal and treat them with surgery, radiation, chemotherapy or a combination of approaches, none of them pleasant options…

This is simply not true. Any pathologist or oncologist or breast cancer surgeon worth his or her education could tell you that not all breast cancers are the same. There’s a spectrum of disease. Some cases warrant more treatment than others, and some merit distinct forms of treatment, like Herceptin, or estrogen modulators, surgery alone…Very few forms of invasive breast cancer warrant no treatment unless the patient is so old that she is likely to die first of another condition, or the patient prefers to die of the disease. When and if they do arise, slow-growing subtypes should be evident to any well-trained, modern pathologist.

“Mammograms Spot Cancers That May Not Be Dangerous,” said WebMD, yesterday. This is feel-good news, and largely wishful.

A dangerous message, IMO.

Addendum, 4/15/12: The abstract of the Annals paper includes a definition of “overdiagnosis” that is absent in the body of the report: “…defined as the percentage of cases of cancer that would not have become clinically apparent in a woman’s lifetime without screening…” I acknowledge this is helpful, in understanding the study’s purpose. But this explanation does not clarify the study’s findings, which are abstract. The paper does not count or otherwise directly measure any clinical cases in which women’s tumors either didn’t grow or waned. It’s just a calculation. – ES

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Harsh Words, and Women’s Health at Risk

I’ll open with a confession –

Women’s health has never really been at the heart of ML. Your author has, historically, relegated subjects like normal menstruation, healthy pregnancy and reproduction and natural menopause to her gynecologist friends. Sure, I learned about the facts of life. I even studied them in med school and answered questions, some correctly, along the way. By now, I’ve lived through these real life-phases directly. But these topics never drew me. That’s changed now.

Women’s care – and lives, in effect – are jeopardized on three fronts:

First, on birth control. Last week the Senate narrowly tabled a move to limit insurers’ responsibility to cover contraception. The vote on the so-called “conscience” amendment was 51-48. What this tells us is that essentially half of that powerful group either agrees with limiting women’s access to birth control or sees it as dispensable in the context of political aims.

The very fact that the proposal reached the Senate floor is disturbing. Without access to birth control, women –  including teenagers, people with significant medical problems that can be exacerbated by pregnancy, those who can’t afford to feed another child, and some who are already troubled or otherwise might not be ready or prepared to have children – are much more likely to become pregnant. It shouldn’t take a doctor to articulate this obvious point, and I can’t understand why so many are silent on it, but since so few physicians and the AMA in particular hasn’t issued any statement on this, I’ll stick my neck out and say it clearly: Lack of contraception puts women and their conceivable future-kids at risk for health problems that could be avoided.

The language surrounding the amendment is problematic, besides. Who are the anti-birth control legislation-writers to imply that “conscience” is involved in withholding contraception, and not the other way around? It’s like the “pro-lifers” who’ve implied that the rest of us aren’t.

Second, on access to safe abortions. I respect that some people think it’s wrong to terminate a pregnancy. But I also know that plenty of women, especially young women, get pregnant who don’t want to be pregnant. Regardless of who’s “responsible” – and any reader of this blog knows I’m no sucker for finger-pointing and behavior blame games – the bottom line is that if abortions become out-of-reach, women will suffer hemorrhage, life-threatening infections, permanent infertility  and premature deaths.

Hard to know how many women had ill effects or died from botched abortions before January, 1973, when the Supreme Court issued its decision on Roe vs. Wade. Like most women of my generation, I know of those unfortunate outcomes only indirectly. Still, I can’t rid my brain of the scary, unclean place Natalie Wood visits with a wad of cash in the 1963 movie Love with the Proper Stranger, or the tragic outcome when actor Gael García Bernal takes his pregnant love to an abortionist in the film Crime of Padre Amaro, set a decade or so ago in Mexico. But the real scoop comes from older physicians and nurses, here and now. When I was in med school in the 1980s, they told me stories of women and girls showing up in the emergency room bleeding, pale… dead.

As outlined by editorialists and writers elsewhere, mergers of Catholic hospitals with other medical centers threaten to reduce or eliminate access to abortions in some rural areas. In states like Texas, the physical and emotional rigmarole to which pregnant women are subjected prior to an abortion – including mandatory listening to a description of the fetal organs and a discussion loaded make what might be a tough decision unbearable, especially if the woman lacks confidence.

Which leads me to the third point of vulnerability – that women should be able to obtain care without intimidation or emotional abuse.

When Rush Limbaugh spoke last week, he wasn’t just talking about one Georgetown Law student. He was speaking to and about millions of young women who are sexually active. He called them sluts and insinuated they are like prostitutes. Adding insult to verbal injury, he said he’d like to watch videos of the sex. You could say who cares, he’s just some right-winged showman blowing off steam and misogyny. But this is a man who speaks to conservative leaders and feeds ideas to many households in America. Scary that the Republican front-runners, men who would be President of the United States next year, didn’t call Rushbo out. Rather, they let it go. As they might your daughter’s health, or access to birth control, or to a safe abortion.

In this new climate of shame, it’s easy to imagine a girl in some communities might feel really, really bad about herself simply for being sexually active. Whether she’s 17 years in high school, or 21 years in college, or 25 and maybe a department store clerk – and possibly lonely or confused – she may be embarrassed to ask for birth control. The Scarlet C, Robert Walker aptly called it yesterday.

The paradox is that this kind of rough talk, posturing and in some states, puritanical law-making, make it more likely that a sexually active young woman will become pregnant. And if she does become so, now, she may delay seeing a doctor because she fears his or her moral judgment about her behavior. And that leads to less healthy outcomes, and more deaths – fetal and maternal.

This is a serious health issue. I wish more doctors would speak out about it.

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Komen Update – Future Plans?

As many ML readers are aware, late this morning, the Susan G. Komen Foundation announced it will not cut current grants or funding to Planned Parenthood. This reversal comes as welcome news to those who support the agency and its work. The New York City branch issued this statement.

Still, many breast cancer advocates, activists and others question Komen’s priorities. This episode draws attention to debate within the BC community about the relative merits of spending charity dollars on screening, education, awareness, research and other concerns.

The long-term fallout from this week’s news and the agency’s reversal aren’t known. As I suggested earlier, Komen’s leadership might take this opportunity to reassess its mission and goals.

—-

 

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A Note on the Komen Fiasco

When I first heard the Susan G. Komen Foundation is nixing its financial support of Planned Parenthood, I thought it might be a mistake. Maybe a rogue affiliate or anti-choice officer had acted independently of the group’s core and mission, and the press got the early story wrong. I waited for Nancy G. Brinker, Komen’s surviving sister, to step in and deny the BC agency’s change of plans. That didn’t happen.

Rather, in a stilted video released yesterday, Brinker defends her agency’s decision as part of a “strategic shift” having to do with funding for any organization under investigation. That’s a bogus excuse, as others have detailed.

Komen, the world’s largest BC agency, has been under scrutiny for some time. Through its early fundraising campaigns and walks, the group raised public awareness – and discussion – of the disease. Since its inception in 1982, the agency has invested over $1.9 billion in education, breast-cancer screening, research and other grants. The discourse has changed, though. Now, many are critical of Komen’s historic focus on BC education and screening, including mammography, and tire of seeing so much pink.

This week’s outcry over the agency’s political turn has been fierce. It’s not too late for Komen’s leadership to take note, change course and revise its agenda.

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The Iron Lady, a Film About an Aging Woman

image, "the Iron Lady"

Over the weekend I saw the Iron Lady, a movie about Margaret Thatcher, the former Prime Minister of England.  I expected a top-notch, accented and nuanced performance by Meryl Streep, and got that.

The film surprised me in several respects. It’s really about aging, and how a fiercely independent woman withers. The camera takes you within her elderly, blurry, husband-conjuring mind. She’s forgetful and rambling, but maintains an interest in current events, and ideas. She looks back on events in her life with pride and, seemingly, some regrets.

Well done, worth seeing!


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The BC Sisterhood Takes on Sex After Cancer and What Oncologists Don’t Say

A hit in the women’s breast cancer Twitter league came my way from the Breast Cancer Sisterhood®. Brenda Coffee, a survivor and founder of the Survivorship Media Network, offers a serious post on What Your Oncologist Doesn’t Tell You About Sex.

There’s a music video, Don’t Touch Me that’s annoying but depressingly right on how some women feel in menopause –  a frequent and under-discussed aspect of chemo or hormonal therapy for BC, followed by a grounded and unusually frank discussion about what happens to women after cancer treatment, menopause and sex.

Brenda’s right; none of this was included in my med school curriculum or oncology fellowship. Although, in fairness and quite seriously, this was a subject on mine and some other oncologists’ radar long ago. Cancer treatments can have lasting effects on sexuality in men and women.

Worth checking out Brenda’s network and her candid post. You can follow her @BCSisterhood on Twitter.

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Cervical Cancer Screening Update: on Pap Smears, Liquid-based Cytology and HPV

The latest issue of the Annals of Internal Medicine contains 2 noteworthy papers on cervical cancer screening. The first, a systematic review of studies commissioned by the USPSTF, looked at 3 methods for evaluating abnormalities in women over 30 years:

high-grade cervical cell dysplasia (Dr. E. Uthman, Wikimedia Commons)

1. Conventional cytology (as in a Pap smear; the cervix is scraped and cells splayed onto a microscope slide for examination);

2. Liquid-based cytology (for LBC, the NHS explains: the sample is taken as for a Pap test, but the tip of the collection spatula is inserted into fluid rather than applied to slides. The fluid is sent to the path lab for analysis);

3. Testing for high-risk HPV (human papillomavirus). Currently 3 tests have been approved by the FDA in women with atypical cervical cells or for cervical cancer risk assessment in women over the age of 30: Digene Hybrid Capture 2 (manufactured by Quiagen), Cobas 4800 HPV (Roche) and Cervista HR HPV (Hologic); another Roche Diagnostics assay, Amplicor HPV, awaits approval.

These HPV assays use distinct methods to assess DNA of various HPV strains.

There’s a lot of jargon here, and I have to admit some of this was new to me despite my nearly-due diligence as a patient at the gynecologist’s office and my familiarity as an oncologist with the staging, clinical manifestations and treatment of cervical cancer. Who knew so many decisions were made during a routine pelvic exam about which manner of screening?

The main points I took away from this paper:

1. Liquid-based cytology is similar to conventional Pap smear cytology for detecting high-grade dysplasia (abnormal cells) and cervical cancer.

2. It seems that at some medical centers, and possibly overall, there’s a lower proportion of inadequate cell specimens when practitioners skip the slides and use the liquid method. This means that fewer women need be called back for another procedure.

3. Finding HPV sequences in the cervix yields many false positives, in terms of malignancy.

The researchers conclude that further studies are needed to sort out how HPV testing can improve or supplement cervical cancer screening. The main limitation is that many young women are infected with potentially cancer-causing strains of HPV, but most don’t get cervical cancer. When cervical cancer does develop that’s usually later on, a decade or longer after the relevant viral infection.

The second Annals article, a helpful narrative review, considers the practical implications of the above findings. The authors state that over 40 types of HPV can infect the cervix. They review that progression to cancer occurs along these 4 steps: HPV transmission, acute infection, persistent infection causing precancerous changes and eventually, in a subset of those infected, invasive cervical cancer.

Figure 1 is remarkably clear:

Prevalence of high-risk HPV and incident cases of cervical cancer in the U.S., 2003–2005. Surveillance Epidemiology and End Results (SEER) data for incident cases among females aged 15 to 19 years and 50 to 64 years.

The graph shows that the prevalence of HPV infection is highest among teens and women in their early 20s, and decreases in older women. By contrast, the incidence of cervical cancer rises steadily in women over 30 years and remains elevated among women in their 40s. The authors show, separately, that the rate of cervical cancer in older women is low.

The central point is that high-risk HPV infection and associated inflammation of the cervix are common in young women, but cervical cancer is rare among those under 30 years. The investigators conclude that cervical cancer screening in women younger than 20 years may be harmful. They also state that evidence supports discontinuation of cervical cancer screening in most women who are over 65 years old.

Two asides on this otherwise non-bloggy topic –

It’s great that the Annals provides the full text of these papers open-access, free of charge to the public.

Amazing how well-accepted is the concept of some viruses causing cancer, today. This was a heretical idea 25 years ago in academic medicine; now it’s dogma.

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On Alcohol and Breast Cancer, Guilt, Correlations, Fun, Moderation, Doctors’ Habits, Advice and Herbal Tea

Few BC news items irk some women I know more than those linking alcohol consumption to the Disease. Joy-draining results like those reported this week serve up a double-whammy of guilt: first – that you might have developed cancer because you drank a bit, or a lot, or however much defines more than you should have imbibed; and second – now that you’ve had BC, the results dictate, or suggest at least, it’s best not to drink alcohol.

The problem is this: If you’ve had BC and might enjoy a glass of wine, or a margarita or two at a party, or a glass of whiskey, straight, at a bar, or after work with colleagues, or when you’re alone with your cat, for example, you might end up feeling really bad about it – worse than if you had only to worry about the usual stuff like liver disease and brain damage, or if you could simply experience pleasure like others, as they choose.

The newly-published correlative data, in the Nov 2 issue of JAMA, are clear. The findings, an offshoot of the Nurses’ Health Study, involve over 105,000 women monitored from 1980 until 2008. The bottom line is that even low levels of alcohol consumption, the equivalent to 3-6 drinks per week, are associated with a statistically significant but slight increase in breast cancer incidence. And the more a woman drinks, the more likely she is to develop breast cancer.

All things considered, it might be true that alcohol is a breast carcinogen, as Dr. Steven Narod calls it in the editorial accompanying the research study. Still, there’s no proof of cause and effect: Other factors, like consuming lots of food or perhaps some yet-unidentified particularity about living in communities with abundant food and alcohol, are potential co-variables in this story. But what if it is true?

From the editorial:

These findings raise an important clinical question: should postmenopausal women stop drinking to reduce their risk of breast cancer? For some women the increase in risk of breast cancer may be considered substantial enough that cessation would seem prudent. However, there are no data to provide assurance that giving up alcohol will reduce breast cancer risk.

How I see it is this: Everything’s best in moderation, including enjoyment of one’s life. You work, you rest, you have some fun.

This evidence is not like the strong data linking cigarettes to smoking that officials sat on for a few decades under the influence of the tobacco industry. This is a plausible, mild, and at this point well-documented correlation.

I don’t deny the sometimes harmful effects of alcohol; no sane physician or educated person could. But if you have a glass of wine, or even a second, so long as you don’t drive a car or work while affected, I don’t see it as anyone’s business but your own. More generally, I worry about how much judging there is by people who behave imperfectly, and how that can make individuals who are good people in most ways feel like they don’t deserve to be happy or enjoy their lives.

Women, in my experience, are generally more vulnerable to the put-downs of others. And so my concern about the BC-alcohol link is that this will, somehow, be used, or have the effect of, making survivors or thrivers or women who haven’t even had breast cancer feel like they’re doing the wrong thing if they go to a party and have a drink. And then they’ll feel badly about themselves.

Really I’m not sure what more to say on this loaded topic, except that it points to the deeper and broader ethical dilemma of doctors who are not all perfect examples of moderation, expecting and asking other people to change their personal habits when they themselves like to go out and have fun, and drink, at parties, or have wine in the evenings over dinner in the privacy of their homes.

How shall I resolve this post?

Last night I sipped Sleepytime tea, manufactured by Celestial Seasonings, before reading a book. The stuff is said to be 100% natural, with “a soothing blend of chamomile, spearmint and lemongrass.” I tried it first a few weeks ago and, by a placebo effect or through real chemistry, it helps me sleep more soundly.

I’ve absolutely no idea what are the effects of “Sleepytime tea” on breast cancer. It might help, it might hurt, or it might do nothing at all.

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Arizona Cheerleaders Cause Community Stir With Breast Cancer Awareness Shirts

This story, shared today by Debbie Woodbury, warrants ML Annals of Pink inclusion:

The Arizona Republic reports on a divided community in Gilbert, AZ. At issue is the high school cheerleading team’s plan to wear pink tee shirts with the slogan: “Feel for lumps – save your bumps” on the back. The group’s intention was to raise awareness and funds for the Susan G. Komen Foundation. 

The school’s principal said no to the controversial outfits due to their “unacceptably suggestive” content.

What strikes me, among other interesting aspects of this story and what it reflects about BC awareness in 2011, is how the arguments (so needless!) about fundraising play out so differently, depending where you live and the newspapers you might read.

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Glad to Spot a Pink Ribbon

This morning I walked into a Starbucks and noted a woman wearing a little pink ribbon on the lapel of her suit. She appeared to be in a meeting, speaking seriously with a small group of people dressed for business.

How great is that, I thought, that she wears the pink ribbon unabashedly, in this October of 2011. She sees nothing wrong with raising awareness about breast cancer, or expressing her concern about this killer of women. Kudos!

In some circles now it’s fashionable to bash pink symbols, to say how breast cancer shouldn’t be prettified, or commercialized, or overblown. What I’d say is, of course, the disease isn’t beautiful, or good, or inherently profitable, or to be perceived as a gift. It’s none of those things.

But we take for granted, lately, how open people are about breast cancer and its complications. Twenty years ago, and even ten, many women I knew took their treatments silently. Few disclosed their illness to others in the community. Many lacked open sources of information or support. For some, breast cancer was a source of shame.

Times have changed, indeed.

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NEJM Publishes New Review on Breast Cancer Screening

With little fanfare, the NEJM published a feature on breast cancer screening in its Sept 15 issue. The article, like other “vignettes” in the Journal, opens with a clinical scenario. This time, it’s a 42 year old woman who is considering first-time mammography.

The author, Dr. Ellen Warner, an oncologist at the University of Toronto, takes opportunity to review updated evidence and recommendations for screening women at average risk for the disease. She outlines the problem:

Worldwide, breast cancer is now the most common cancer diagnosed in women and is the leading cause of deaths from cancer among women, with approximately 1.3 million new cases and an estimated 458,000 deaths reported in 2008.(1)

On screening:

The decision to screen either a particular population or a specific patient for a disease involves weighing benefits against costs. In the case of breast-cancer screening, the most important benefits are a reduction in the risk of death and the number of life-years gained….

She breaks down the data for mammography by age groups:

For women between the ages of 50 to 69 the evidence is clear, she says. For those over 70, there are little data to support breast cancer screening. There’s a consensus that screening isn’t appropriate for women with serious coexisting illnesses and a life expectancy of less than 5-10 years.

For those between the ages of 40-49, Warner challenges the revised 2009 USPSTF recommendations on several counts. She critiques those authors’ weighting of data from the Age trial of 161,000 women, emphasizing the use of an antiquated (single view) mammography technique and flawed statistics. She considers:

…However, this change in remains highly controversial,22, 23 especially because of the greater number of years of life expectancy gained from preventing death from breast cancer in younger women. According to statistical modeling,19 screening initiated at the age of 40 years rather than 50 years would avert one additional death from breast cancer per 1000 women screened, resulting in 33 life-years gained.”

What I like about Warner’s analysis, besides its extreme attention to details in the data, is that she’s not afraid to, at least implicitly, assign value to a procedure that impacts a young person’s life expectancy relative to that of an older person.

She goes on to consider digital mammography and the Digital Imaging Screening Trial (DMIST [NCT00008346]) results. For women under 50 years, digital mammography was significantly more sensitive than film (78% vs. 51%).

The article is long and detailed; I recommend the full read including some helpful tables, with references to the major studies, and charts.

In concluding, the author, who admits receiving grant support from Amersham Health (a GE subsidiary), consulting fees from Bayer and lecture fees from AstraZeneca, returns to the hypothetical patient, and what might be said to a woman in her 40s who lacks an outstanding risk (such as a genetic disposition or strong family history):

…Mammography screening every 2 years will find two out of every three cancers in women her age, reduce her risk of death from breast cancer by 15%. There’s about a 40% chance that further imaging (such as a sonogram) will be recommended, and a 3% chance for biopsy with a benign finding….

In my opinion (ES) this is key – that the chances of a false positive leading to biopsy are only 3% for a woman in her 40s. If those biopsies are done in the radiology suite with a core needle, every 2 years for women of average risk, the costs of false positives can be minimized.

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1 in 70 Women Develops Breast Cancer Before Reaching 50 Years

A post in yesterday’s Well column, about coverage of breast cancer by the media, focused on the first-person narrative of NBC’s Andrea Mitchell. Journalist Tara Parker-Pope writes:

Her announcement has generated much discussion in the blogosphere, including an analysis by Gary Schwitzer, publisher of HealthNewsReview.org, who writes that Ms. Mitchell made some missteps in discussing her cancer.

The Times column goes on to consider what was said, and how it might have been said better, and I agree with much of it. But mainly it’s a meta discussion, journalists talking about how other journalists consider breast cancer facts, figures and narratives.

Buried deep is this number, that according to the NCI, one in 69, or for the sake of simplicity – approximately 1 in 70 – women in the U.S. will receive a diagnosis of BC in her forties. That is an astonishingly enormous proportion of women under 50 years affected by a devastating disease.

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Should You Tell Your Employer When a Loved One Is Ill?

An article caught my attention in the September AARP Bulletin:

The Caregiver’s Dilemma considers the 61.6 million people in the U.S. who care for older relatives or friends. People with jobs are, understandably, unsure if they should let their boss or supervisor know they’re caring for someone who’s sick. This indirect cost of illness and aging in America is said to tally $33.6 billion each year.

The pressure on workers is tough, writes Sally Abrahms:

Many employees are in that elder care-giving boat, yet workers with work-family conflicts are often reluctant to raise the issue with superiors. They fear they’ll be viewed as not committed enough, or receive bad year-end reviews. They may also think that discussing their personal life is unprofessional or sense resentment from colleagues and the boss, who may have to pick up the slack during their absences…

The article reminded me of the dilemma faced by cancer patients, and by the parents or children of anyone who’s got a serious diagnosis and needs help. How much to tell the boss?

It’s a tough economy.

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Medical Aspects of ‘The Help’: The Plight of a Woman with Recurrent Miscarriages

the character Celia, in "The Help"

Last weekend I saw The Help, a movie on race relations in Jackson, Mississippi 50 years ago with lingering implications for people who hire “help” to take care of their children and tend to their personal business anywhere in the world, including now. It’s a heavy-handed, simple-message and nonetheless very enjoyable film, with fine acting and imagery, based on the book of the same title by Katherine Stockett.

One element of the narrative interested me from the medical perspective, having to do with the plight of a pale, thin and sexy young woman who’s marginalized by the white Jackson social elite. The character Celia, portrayed with flair by Jessica Chastain, lives, isolated, on an out-of-town plantation. She spends her days alone while her husband’s at work. The nominally proper women in town, while playing bridge and otherwise gathering, call her “white trash,” and she sometimes lives up to their prejudices by drinking too much and behaving erratically.

It turns out the young woman’s having a hard time because she’s unable to bear children. She feels inadequate and fears her husband might leave her if he found out. Her history of recurrent miscarriages is discovered by the African American maid, Minny, who comes to work with her. In a revealing scene Minny finds Celia locked in the bathroom, severely bleeding from a miscarriage and crying. The maid, played with conviction by Octavia Spencer, helps her to recover, clean up, and bury the fetus in a shoebox in the yard, nearby three other small burial sites. With this, the young woman’s odd behavior becomes comprehensible.

I couldn’t help but think of countless women of earlier eras, and friends I’ve known in my adulthood, and women I’ve treated as a physician, who felt really bad about their inability to bear children. These days, with fertility treatments and work-ups for miscarriages so prevalent in communities like mine, we don’t see so many cases like Celia’s. It used to be a common problem, and it still is in many regions in the U.S and certainly in other parts of the world, for women who have difficulty conceiving or carrying babies to term, not just to not have children, but to become sad, and feel inadequate about themselves as women.

The Help is a worthwhile film at many levels, with fine acting, a good, PC message and story. I hope movie-goers will take special note of Celia’s predicament.

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Mammography Update!

This week I’ve come across a few articles and varied blog posts on screening mammography. The impetus for rehashing the topic is a new set of guidelines issued by the American College of Obstetricians and Gynecologists. That group of women’s health providers now advises that most women get annual mammograms starting at age 40.

Why every year? I have no idea. To the best of my knowledge, there are no data to support that annual mammograms are cost-effective or life-saving for women in any age bracket at normal risk for BC.

Pertinent also, is a recent paper* in the Annals of Internal Medicine supporting a personalized approach to BC screening and mammography for women over the age of 40, and an editorial* to go with it.

“Talk to your doctor,” is the point for patients. (Women’s breasts are not all the same.)

“Talk with your patient,” is the point for doctors: Consider your patient’s breast density, family health history and personal preferences. Great idea!

We need an Annals paper to tell us this?

My personal view, synthesizing all the medical literature of which I’m aware, and taking account all of my prior experiences as a practicing oncologist, and not forgetting I’m a woman, now 50, who had an early-stage breast cancer discovered by a radiologist – and this is not medical advice – is as follows:

For women of normal risk, such as without a strong family history or a prior cancer:

1. Start with a baseline, digital mammogram at age 40. The image should be digital first, because this kind of technology is better for visualizing dense breast tissue which is more common in pre-menopausal, younger women and second, because digital images can more easily be shared with another doctor, for a second or more expert opinion if necessary.

2. Get mammograms every other year, unless there’s a significant abnormality that requires follow-up sooner. Until what age? Hard to say. (A complex topic… hold that thought for another post.)

3. Supplement mammography every other year with monthly self-examination of the breast. This inexpensive method of feeling one’s own breasts, regularly and methodically, has not been shown to save lives in randomized clinical trials. But I am convinced that if it’s done right – when a gynecologist, PCP, internist or other caregiver takes the time to teach her patients how to do the breast self-exam properly  – as I used to instruct my patients in the clinic, women can help themselves to catch breast tumors early.

4. Mammograms should be done, exclusively, by appropriately-trained radiologists who spend the bulk of their time reading mammograms, performing sonograms of the breast and taking occasional biopsies, as appropriate. (Sorry, general radiologists, but that’s how it is. Would you want your mother’s breast image examined by a radiologist who also reads hip films and MRIs of the brain?) The rate of false positives is lower when mammograms are performed by specialized “breast” radiologists.

5. Take advantage of the fact that mammography centers have been regulated for nearly two decades by the FDA. Be sure that the place where you get your mammogram is MQSA-accredited.

All for now –

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Taking Care of Yourself When Someone You Love is Ill

This week a close relative was hospitalized and turns out to have a serious condition.  He’s not a blog-lover, so I’ll keep this abstract:

When a loved one gets sick, you have to take care of yourself. It’s hard to do your work, and to be there 24/7 for the rest of your family, and to eat nutritious, non-hospital cafeteria-type meals, and to find time to run or swim or whatever it is you do to take care of the one life you have.

So I’ll go to the gym today, just for half an hour. I’ll gor for a swim tomorrow, even if it’s just for half my usual laps: 30 minutes is better than no time in the water; 20 minutes is OK too, far better than not going at all. My intention is to keep up my routine, albeit reduced and adjusted, through what will hopefully be a long haul.

And I’ll write when I can.

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What’s Next on the Big C? (Hopefully a Second Opinion)

(Hopefully a second opinion)

When I last wrote on The Big C, a Showtime series in which the actress Laura Linney portrays a woman in her forties with advanced melanoma, I considered some of the options she might choose when the series resumes next Monday night.

Laura Linney, in Showtime's 'Big C'

At the end of Season 1, she elected to try a course of IL-2 as was recommended by her young oncologist. Meanwhile, the FDA has approved Ipilimumab (Yervoy), an antibody treatment that revs up the immune system. And she’s in line, according to the script, for possible entry into a clinical trial that likely involves a targeted therapy, like vemu­rafenib for patients whose malignant cells have a genetic mutation in B-RAF.

What I expect Cathy will do, before anything else happens and she receives any additional non-urgent treatment for her advanced melanoma, is get a second opinion. She’s a smart, sensible sort; in retrospect it’s hard to believe she didn’t do this earlier on and before starting the IL-2 therapy.

I wonder, also, if one of her family members or friends will do some research about melanoma on the Internet. That would help her find a doctor with appropriate expertise, and better know what questions she should ask of the oncologist during the consultation.

That’s all on Cathy’s decision, until next week.

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